BHSIA Target Data Elements Assessment / Admission Setup



|[pic] |Target Data Elements |STAFF IDENTIFICATION |

| |Assessment / Admission Setup |      |

| | |AGENCY NUMBER |

| | |      |

|Section I: Client Identification |

|1. LAST NAME |2. FIRST NAME |3. MIDDLE NAME |4. OTHER LAST NAME |

|      |      |      |      |

|5. GENDER |6. DATE OF BIRTH |7. SOCIAL SECURITY NUMBER * |8. WASHINGTON DRIVER’S LICENSE OR ID NO.       |

|Male Female |      |      | |

|9. WHICH RACE / ETHNICITY GROUP WOULD YOU IDENTIFY YOURSELF WITH (CHECK A MAXIMUM OF FOUR THAT APPLY) |

| Asian Indian | Middle Eastern | Non-federal tribe |

|Black / African American |Native American | |

|Cambodian |Other Asian | |

|Chinese |Other Pacific Islander | |

|Filipino |Other Race | |

|Guamanian |Refused to Answer | |

|Hawaiian (Native) |Samoan | |

|Japanese |Thai | |

|Korean |Vietnamese | |

|Laotian |White / European American | |

| | |Tribal Code (No. 1)       |

| | |Tribal Code (No. 2)       |

|10. SPANISH/HISPANIC/LATINO (CHECK ONE) | | |

|Cuban |Not Spanish/Hispanic/Latino |Puerto Rican |

|Mexican, Mexican American, Chicano |Other Spanish/Hispanic/Latino |Refused to Answer |

|NOTES |

|      |

|* The Social Security Act provides for the collection of Social Security Number to assist in the administration of public funded programs. |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section II: Assessment Setup |

|1. ASSESSMENT DATE |4. ASSESSMENT TYPE (CHECK ONE) |

|      |CD and Gambling Gambling |

| |Deferred Prosecution Involuntary Commitment |

| |DUI/Dept. of Licensing Other than the Above (CD) |

| |Expanded Assessment |

|2. ASSESSMENT TIME | |

|   :    A.M. P.M. | |

|3. DATE OF FIRST CONTACT | |

|      | |

|5. ENTRY REFERRAL (CHECK ALL THAT APPLY) |

| At Risk Youth (ARY / CHINS) | First Steps or PPP Case | Pharmacist |

|Attorney |Gambling Facility |Phone book |

|BECCA Involved |Group Care |Police |

|Court / Probation |24 Hour Help line |School/Education |

|DCFS / CPS |Involuntary Commitment |Self Help |

|Department of Corrections (DOC) |JRA |Self / Family |

|Department of Licensing (DOL) |Mass media |Social Security Administration |

|Detoxification Facility |MD / Primary Care Provider |Website |

|Diversion |Mental Health Provider |Other:       |

|DSHS Community Services Office |Other Alcohol / Drug Facility | |

|Employer / EAP |Other Health Care Provider | |

|6. CLIENT REGISTRY PARTICIPATION |7. REGISTRY STATUS DATE       |8. REFERRING CSO/HCS |9. CSO REFERRAL DATE       |

|Permitted Refused Revoked | |      | |

|Section III: Admission Setup |

|1. ADMISSION DATE |4. BECCA admission? Yes No |

|      |5. Is this an ADATSA admission? Yes No |

| |6. Admission type: CD Gambling Both |

|2. ADMISSION TIME | |

|   :    A.M. P.M. | |

|3. DATE OF FIRST CONTACT | |

|      | |

|7. ENTRY REFERRAL (CHECK ALL THAT APPLY) |

| At Risk Youth (ARY / CHINS) | First Steps or PPP Case | Pharmacist |

|Attorney |Gambling Facility |Phone book |

|BECCA Involved |Group Care |Police |

|Court / Probation |24 Hour Help line |School/Education |

|DCFS / CPS |Involuntary Commitment |Self Help |

|Department of Corrections (DOC) |JRA |Self / Family |

|Department of Licensing (DOL) |Mass media |Social Security Administration |

|Detoxification Facility |MD / Primary Care Provider |Website |

|Diversion |Mental Health Provider |Other:       |

|DSHS Community Services Office |Other Alcohol / Drug Facility | |

|Employer / EAP |Other Health Care Provider | |

|8. REFERRING AGENCY |9.REFERRING ASSESSMENT DATE |

|      |      |

|10. REFERRING CSO |11. CLIENT REGISTRY PARTICIPATION |12.REGISTRY DATE |

|      |Permitted Refused Revoked |      |

|NOTES |

|      |

|Assessment/Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section IV: Client Milestones |

|A. LANGUAGE SKILLS |

|1. PRIMARY LANGUAGE USED IN YOUR HOME IF OTHER THAN ENGLISH (CHECK ONE BOX ONLY) |

| American Sign Language | Farsi | Ilocano | Marathi | Samoan |

|Amharic |Finnish |Indian (General) |Mien |Spanish |

|Arabic |French |Italian |Norwegian |Tagalog |

|Cambodian |German |Japanese |Other Language |Thai |

|Cantonese |Greek |Korean |Polish |Tigrigna |

|Chinese |Gujarati |Lakota Sioux |Puyallup |Ukrainian |

|Czech |Hindi |Laotian |Romanian |Unknown Language |

|Dutch |Hmong |Malay |Russian |Vietnamese |

| |Hungarian |Mandarin |Salish |Yakama |

|B. FAMILY AND SOCIAL ARRANGEMENTS |

|1. In the last 30 days: How many times have you attended a self-help session related to recovery from substance abuse or dependence? (199 means not collected) |

|      |

|2. RESIDENCY (CHECK ONE BOX ONLY) | | |

|Controlled Environment |Jail/Prison |Student Residence |

|Drug-Free Shared/Transitional Housing |No Stable Arrangement |Transient Quarters |

|Foster/Group Home |On the Street |Work/Training Release Center |

|Homeless Shelter/Mission |Personal Residence | |

|Hospital/Other Institution |Single Room Occupancy | |

|3. STREET ADDRESS |4. CITY |5. STATE |6. ZIP CODE |

|      |      |   |      |

|7. COUNTY |8. TELEPHONE NUMBER |

|      |      |

|9. Do you have a valid driver’s license (ASI)? |10. Do you have an automobile available (ASI) |

|Yes No |Yes No |

|11. MARITAL STATUS (CHECK ONE BOX ONLY) |

|Divorced Married or Committed Relationship Never Married Separated Widowed |

|12. Are you satisfied with your current marriage or relationship status (ASI)? Yes No Indifferent |

|13. WHO ARE YOU LIVING WITH (CHECK ONE BOX) |

| Alone | Other Family Members with or without | Spouse/Partner Alone |

|Child(ren) Alone |Child(ren) |Spouse/Partner and Child(ren) |

|Foster parents/Group Home |Parent(s)/Parent(s) with Child(ren) | |

|Friends |Roommates | |

|14. HOW DO YOU IDENTIFY YOUR SEXUAL ORIENTATION? |

|Bisexual Choosing Not to Disclose Gay/Lesbian Heterosexual Questioning Transgender |

|NOTES |

|      |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section IV: Client Milestones (Continued) |

|B. FAMILY AND SOCIAL ARRANGEMENTS (CONTINUED) |

|15. Persons in household (including you):       |

|16. Number of your children or siblings under 18 years living with you:       |

|17. Number of your children or siblings under 18 years not living with you:       |

|18. Number of other children under 18 years living with you:       |

|19. In the last thirty days, have you had significant periods in which you have experienced serious problems getting along with (ASI): |

| Children | Father | Other Significant Family Member |

|Close Friends |Mother |Sister/Brother |

|Co-workers |Neighbors |Spouse/Sexual Partner |

|20. In the last 30 days (ASI): |

|How many times have you had serious conflicts with your family members:       |

|How troubled or bothered have you been by family problems (ASI Scale Number):       |

|21. How important to you now is treatment or counseling for these family problems (ASI Scale Number):       |

|22. Is your current living environment conducive to recovery? Yes No |

|23. IF UNDER 18 YEARS, HOW MANY TIMES HAVE YOU RUN AWAY IN THE PAST YEAR? |

| 0 times | 2 times | 4 times | 6 to 10 times | More than 20 times |

|1 time |3 times |5 times |11 to 20 times | |

|C. EDUCATION |

|1. ACADEMIC/TRAINING ACHIEVEMENT (CHECK ONE BOX ONLY) |

| AA Degree (Academic) | No Degree | Vocational Training (Certificate) |

|AA Degree (Vocational) |Post-Graduate Degree |Vocational Training (No Certificate) |

|GED |Undergraduate Degree | |

|High School Diploma |Unknown | |

|2. YEARS OF EDUCATION:       |4. CURRENT SCHOOL STATUS (CHECK ONE) |

|3. In the last twelve months: | Dropped Out | Not Enrolled |

|How many times have you been suspended from school:       |Expelled |Part Time |

|How many schools have you been expelled from:       |Full Time |Suspended |

|D. EMPLOYMENT AND INCOME |

|1. EMPLOYMENT ACTIVITY (CHECK ONE BOX ONLY) |

| Employed Full-Time | Institutionalized | Retired |

|Employed Part-Time (less than 30 hours) |Military |Under Age Not in Workforce |

|Employed Temporary/On Call/Intermittent |Not in Work Force |Unemployed Not Seeking Work |

|Homemaker |Not Working Due to Disability |Unemployed Seeking Work |

|NOTES |

|      |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section IV: Client Milestones (Continued) |

|D. EMPLOYMENT AND INCOME (CONTINUED) |

|2. PRIMARY SOURCE OF INCOME OR SUPPORT (CHECK ONE BOX ONLY) |

| Disability | Other | Social Security (SSA/SSDI) |

|Family/Friend (most Youth fall here) |Public Assistance |Unemployment Compensation |

|None |Retirement Pension |Wages/Salary |

|3. MONTHLY HOUSEHOLD GROSS INCOME (Immediate family ONLY) |5. In the last 30 days (ASI): |

|      |How many days were you paid for working:       |

| |How much money did you receive from employment:       |

| |How much money did you receive from illegal activities:       |

|4. MONTHLY PERSONAL INCOME (GROSS) | |

|      | |

|E. MILITARY VETERAN |

|1. Have you ever served on active duty in the U.S. Military? |2. What branch of service? |

|Yes No Refused |Air Force Marine Corps |

|Start month/year:       End month/year:       |Army Navy |

| |Coast Guard |

|3. Have you ever been a member of the National Guard or Reserves? |4. Are you the spouse, partner or dependent minor of someone who has served or|

|National Guard No Refused Reserves |is serving in the U.S. Military, National Guard, or Reserves? |

|Start month/year:       End month/year:       |Child Spouse/Domestic Partner |

| |No Widow |

| |Other Refused |

| |Start month/year:       End month/year:       |

|F. PHYSICAL HEALTH |

|1. PREVIOUS MEDICAL TREATMENT – NOT PREVENTATIVE |

| In the last 30 days (ASI): |

|How many days have you experienced medical problems:       |

|How troubled or bothered have you been by these medical problems (ASI Scale Number):       |

|How important to you now is treatment for these medical problems (ASI Scale Number):       |

|(FOR ASSESSMENTS AND ADMISSIONS, PREVIOUS MEANS THE LAST YEAR, FOR DISCHARGE, PREVIOUS MEANS SINCE ADMISSION) |

| 2. Number of previous emergency room visits:       |

|3. Number of previous outpatient/clinic visits:       |

|4. Number of previous hospital inpatient admissions:       |

|5. Number of previous hospital inpatient days:       |

|6. How many times have you been tested for STD in the last year?       |

|YES NO IN NEED |

|7. Currently under care for infectious disease? |

|8. Have you ever had a traumatic head injury that resulted in loss of consciousness? |

|9. Currently under care for traumatic injury? |

|10. Currently under care for continuing illness? |

|11. Currently under care for dental? |

|NOTES |

|      |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section IV: Client Milestones (Continued) |

|H. PHYSICAL HEALTH (CONTINUED) |

|12. DISABILITY – MAJOR LIMITATIONS (CHECK ALL THAT APPLY) |

| ADHD/ADD | Hearing | Mobility | Speech-Impaired |

|Cognitive Impairment |Learning |None |Vision |

|Developmental |Mental/Psychological |Parkinson’s |Other:       |

|13. HAVE YOU EVER BEEN A VICTIM OF DOMESTIC VIOLENCE? |14. ARE YOU CURRENTLY A VICTIM OF DOMESTIC VIOLENCE? |

|Yes No Uncertain |Yes No Uncertain |

|G. PREGNANCY STATUS |

|1. ESTIMATED DUE DATE (MM/DD/YYYY) |2. HAS PRENATAL PROVIDER? |3. PREGNANCY END DATE (MM/DD/YYYY) |

|      |Yes No |      |

|H. MENTAL/PSYCHOLOGICAL CONDITIONS |

|1. PREVIOUS MENTAL TREATMENT (FOR ASSESSMENTS AND ADMISSIONS, PREVIOUS MEANS THE LAST YEAR. FOR DISCHARGE, PREVIOUS |2. DAYS HOSPITALIZED FOR MENTAL TREATMENT |

|MEANS SINCE ADMISSION.) (CHECK ONE BOX ONLY) |      |

|No/NA Unknown With Hospitalization With Outpatient Treatment | |

|3. CURRENT PSYCHOLOGICAL EVALUATION (CHECK ONE BOX ONLY) |

| No Evaluation Made | Psychological Evaluation Made, Problem Diagnosed |

|Problem Indicated, Referral Made |Re-evaluation Needed |

|Psychological Evaluation Made, No Problem Found | |

|4. Does anyone in your immediate family or current living situation have a diagnosed mental illness? Yes No |

|5. In the last 30 days (ASI): |

|How many days have you experienced psychological or emotional problems:       |

|How troubled or bothered have you been by psychological or emotional problems (ASI Scale Number):       |

|6. How important to you now is treatment for these psychological problems (ASI Scale Number):       |

|7. In the past 30 days have you had a significant period of time (that was not a direct result of A/D use) in which you have (ASI): |

| |Yes No |

|a. Experienced serious depression - sadness, hopelessness, loss of interest, difficulty with daily functions? | |

|b. Experienced serious anxiety/tension - uptight, unreasonably worried, inability to feel relaxed? | |

|c. Experienced hallucinations - saw things or heard voices that were not there? | |

|d. Experienced trouble understanding, concentrating, or remembering? | |

|For the next three items below, patient can have been under the influence of alcohol / drugs. | |

|e. Experienced trouble controlling violent behavior including episodes of rage or violence? | |

|f. Experienced serious thoughts of suicide (patient seriously considered a plan for taking his/her life)? | |

|g. Attempt suicide (include actual suicide gestures or attempts)? | |

|8. CURRENTLY RECEIVING MENTAL HEALTH SERVICES? |9. CURRENTLY ON PRESCRIBED PSYCHIATRIC |110. QUADRANT PLACEMENT |

|Yes No In Need |MEDICATIONS? |      |

| |Yes No Unknown | |

|NOTES |

|      |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section IV: Client Milestones (Continued) |

|I. ARRESTS AND LEGAL ISSUES |

|1. PREVIOUS ARREST(S) (FOR ASSESSMENTS AND ADMISSIONS, PREVIOUS MEANS THE LAST YEAR. FOR DISCHARGE, PREVIOUS MEANS SINCE ADMISSION.) (CHECK ALL THAT APPLY) |

| Crime(s) Unknown | Embezzlement | None |

|Criminal Trespass |Forgery |Other Public-Order Offenses |

|Domestic Violence |Fraud (includes bad checks) |Property Crimes |

|Driving Under the Influence |ID Theft |Theft |

|Drug Possession |Malicious Mischief or Disorderly Conduct |Violent Crimes |

|Drug Trafficking or Manufacturing | | |

|2. How many times in the last 30 days have you been arrested?       |

|3. How many times have you ever been charged with (NOTE: Adult offense only) (ASI): |

|Arson       |Forgery       |Rape       |

|Assault       |Homicide       |Robbery       |

|Burglary       |Other Criminal Offense       |Shoplifting       |

|Contempt of Court       |Probation Violation       |Weapons Offense       |

|Drug Related Violations       |Prostitution       | |

|4. CURRENT LEGAL INVOLVEMENT (CHECK ALL THAT APPLY) |

| Awaiting Charges | Drug Court - Adult | Incarcerated, Pre-Trial |

|Awaiting Trial |Drug Court - Juvenile |None |

|Child Custody Issue |In DUI Deferred Prosecution Status |On Probation or Parole |

|Convicted, Awaiting Sentence |In Other Supervised Program |On Trial |

|CPS Court Involved |Incarcerated, Post-Conviction |Petitioning for DUI Deferred Prosecution |

|Diversion | | |

|5. How many days in the past 30 days have you engaged in illegal activities for profit:       (ASI) |

|6. How serious do you feel your present legal problems are (ASI Scale Number):       |

|7. How important to you now is counseling or referral for these legal problems (ASI Scale Number):       |

|J. GAMBLING ISSUE |

|1. In the last twelve months: |Yes No |

|a. Have there been periods when you needed to gamble with increasing amounts of money or with larger bets than before in order to get the same | |

|feeling of excitement? | |

|b. Have you continued to gamble in spite of adverse consequences that have affected your finances, family relationships, work, or other parts of| |

|your life? | |

|c. Have you lied to family members, friends, or others about how much you gamble? | |

|d. Have there been periods lasting two weeks or longer when you spent a lot of time thinking about you gambling experiences or planning out | |

|future gambling ventures or bets? | |

|e. Have you tried but not succeeded in stopping cutting, down, or controlling your gambling behavior? | |

|2. In the last twelve months: |

|a. Have you contemplated or attempted suicide? Yes No |

|b. Have you contemplated or attempted to do physical harm to another person? Yes No |

|3. Score on South Oaks Gambling Screen (SOGS):       |

|NOTES |

|      |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section IV: Client Milestones (Continued) |

|J. GAMBLING ISSUE (CONTINUED) |

|4. In the past 30 days, how many days have you played (enter quantity): |

| Bingo       |Gambling and substance use in the same day       |

|Bowl, pool, golf or other games of skill       |Internet gambling       |

|Card Games (non Casino)       |Lottery, numbers, instant tickets(scratch-offs)       |

|Casino table games       |Other forms of gambling       |

|Dice games, dominoes       |Play slots, poker machines, video lottery terminals       |

|Horses, dogs       |Sports       |

|Gambling more than you can afford       |Stock options, commodities       |

|5. In the past 30 days: |

|a. How much money would you say you spent per week on gambling? $      |

|b. Number of gambling episodes per week       |

|K. SUBSTANCE ABUSE |

|1. If administered a breath test, what were the results:       |

|2. In the past 30 days (ASI): |

|How much money would you say you spent on alcohol: $      |

|How much money would you say you spent on drugs: $      |

|How many days have you experienced alcohol problems:       |

|How troubled or bothered have you been by these alcohol problems (ASI Scale Number):       |

|How important to you now is treatment for these alcohol problems (ASI Scale Number):       |

|How many days have you experienced drug problems:       |

|How troubled or bothered have you been by these drug problems (ASI Scale Number):       |

|How important to you now is treatment for these drug problems (ASI Scale Number):       |

|3. Does anyone in your immediate family or current living situation have an alcohol problem? Yes No |

|4. Does anyone in your immediate family or current living situation have a problem with drugs other than alcohol or tobacco? Yes No |

|5 Does anyone in your immediate family or current living situation have a gambling problem? Yes No |

|6. How many times in the last 30 days have you used alcohol to intoxication:       (ASI) |

|NOTES |

|      |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section IV: Client Milestones (Continued) |

|L. SUBSTANCE USE HISTORY |

|KEY CODES |

|PST CODES |ADMINISTRATION CODES |FREQUENCY OF USE/PEAK USE PER MONTH |

|Primary (1) |Inhalation (I) Oral (O) |1 - No use 4 - 13 or more times |

|Secondary (2) |Injection (J) Other (X) |2 - 1 to 3 times 5 - Daily |

|Tertiary (3) |Intra nasal (N) Smoking (S) |3 - 4 to 12 times 6 - Unknown |

|SUBSTANCES |

| |PST (CHECK ONE BOX | |PST (CHECK ONE BOX |

|SUBSTANCE |PER SUBSTANCE) |SUBSTANCE |PER SUBSTANCE) |

| |1 2 3 | |1 2 3 |

|1. Alcohol | |12. No substance abuse | |

|2. Amphetamines | |13. Other:       | |

|3. Barbiturates | |14. Other Sedatives or Hypnotics | |

|4. Benzodiazepines | |15. Other Opiates and Synthetics | |

|5. Cocaine | |16. Over the Counter | |

|6. Hallucinogens | |17. Oxy/Hydro Codone | |

|7. Heroin | |18. PCP | |

|8. Inhalants | |19. Prescribed Opiate Substitute | |

|9. Major tranquilizers | |20. Substance Unknown | |

|10. Marijuana – Cannabis | |21. Tobacco products (cannot be primary) | |

|11 Methamphetamine | | | |

|1. IN THE FOLLOWING TABLE DESCRIBE SUBSTANCE USE WITH THE ABOVE KEY CODES. |

|PST |SUBSTANCE (CODE) |ADMIN (CODE)|AGE OF |FREQUENCY OF USE |PEAK USE PER |DATE LAST USED |AMOUNT TAKEN/COMMENTS |

| | | |FIRST USE |IN LAST 30 DAYS |MONTH IN LAST |MM/DD/YYYY | |

| | | | |(CODE) |YEAR (CODE) | | |

|1 |   |  |   |  |  |      |      |

|2 |   |  |   |  |  |      |      |

|3 |   |  |   |  |  |      |      |

|  |   |  |   |  |  |      |      |

|  |   |  |   |  |  |      |      |

|  |   |  |   |  |  |      |      |

|2. CURRENT STAGE OF USE | | |

|Chemically Dependent (Addicted) |Experimental Use |In Recovery |

|Abuse |No Significant Problem | |

|3. Have you ever used needles to illicitly inject drugs? Continuously Intermittently Rarely Never |

|4. Inject drugs in the last 30 days? Yes No This option for abort discharge ONLY: Unknown |

|5. Currently use tobacco products: Smoke Chew Both None |

|Ever tried to quit using tobacco products? Yes No |

|Want to quit using tobacco products now? Yes No |

|NOTES |

|      |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section V: Client Referrals, Modality, and Funding |

|Complete the section that corresponds to the client’s assessment or admission. |

| A. ASSESSMENT COMPLETION (NON-ADATSA) |

|REFERRALS |

|1. FORWARD REFERRAL (CHECK ALL THAT APPLY) |

| Alcohol/Drug Information School | CSO | Mental Health Services |

|Alcohol/Drug Treatment |Detoxification |No Referral |

|ATR Services |Gambling Treatment |Other (specify):       |

|CD Involuntary Commitment |Medical/Dental Services |Self-Help Group |

|2. Did you suggest client apply for DSHS Public Assistance? |3. RECOMMENDED ASAM PLACEMENT LEVEL |

|Yes No |      |

|FUNDING SOURCE |

|1. SPECIAL PROJECT STATE |2. SPECIAL PROJECT COUNTY |3. SPECIAL PROJECT AGENCY |

|      |      |      |

|4. CURRENT PUBLIC ASSISTANCE (CHECK ONE BOX ONLY) |

| Applicant | None |

|Aged, Blind or Disabled (ABD) |Refugee Assistance |

|Medicaid Alternative Benefit Plan (ABP) |Supplemental Security Income (SSI; S01) |

|Medical Assistance Only |Temporary Assistance for Needy Families (TANF) |

|5. CONTRACT (CHECK ONE BOX ONLY) |

| Adult Outpatient | Criminal Justice – Innovation | Other/None |

|Adult Residential |Crim Just Ino Hardship Insured |Pregnant/Parenting |

|ATR – Access to Recovery |DOC - COM |TANF (ESA) |

|BRIDGES |DOC - Jail |Tribe MOA (Title XIX) |

|CDDA (COMM) |Gov2Gov (Non XIX) |WA-CARES |

|CDDA (LS) |Indian Health Services (IHS) |WASBIRT |

|Criminal Justice (CJ) |Local Sales Tax |Youth Treatment |

|Crim Just Hardship Insured |Molina – Managed Care | |

|6. FUND SOURCE CD (CHECK ONE BOX ONLY) |

| Agency Funded | Federal Direct | State Direct |

|County Community Services |Other |State DSHS (Non DASA) |

|DOC |Private Pay |Tribal Community Services |

|7. FUND SOURCE GAMBLING (Check One Box Only) |8. TITLE XIX FUNDED |9. GOVERNING COUNTY (If Not County Of Facility) |

|State Direct Private Pay Other |Yes No |      |

|10. ASSESSMENT STAFF ID |11. CASE MONITOR (IF DIFFERENT) |12. ASSESSMENT DURATION |

|      |      |HOURS       MINUTES       |

|13. INTERVIEWER’S SIGNATURE |14. DATE |

| |      |

|NOTES |

|      |

|Assessment / Admission and Discharge |AGENCY NUMBER |STAFF IDENTIFICATION |

|Assess Admit |      |      |

| |CLIENT NAME |

| |      |

|Section V: Client Referrals, Modality, and Funding (Continued) |

| B. ADMISSION COMPLETION |

|1. CURRENT PUBLIC ASSISTANCE (CHECK ONE BOX ONLY) |

| Applicant | None |

|Aged, Blind or Disabled (ABD) |Refugee Assistance |

|Medicaid Alternative Benefit Plan (ABP) |Supplemental Security Income (SSI) |

|Medical Assistance Only |Temporary Assistance for Needy Families (TANF) |

|2. MODALITY (CHECK ONE BOX ONLY) |

| Detoxification | Intensive Inpatient | Recovery House |

|Group Care Enhancement |Intensive Outpatient |Methadone/Opiate Substitution Treatment |

|Housing Support Services |Long-Term Residential |Outpatient |

|3. CONTRACT (CHECK ONE BOX ONLY) |

| Adult Outpatient | Criminal Justice – Innovation | Other/None |

|Adult Residential |Crim Just Ino Hardship Insured |Pregnant/Parenting |

|ATR – Access to Recovery |DOC - COM |TANF (ESA) |

|BRIDGES |DOC - Jail |Tribe MOA (Title XIX) |

|CDDA (COMM) |Gov2Gov (Non XIX) |WA-CARES |

|CDDA (LS) |Indian Health Services (IHS) |WASBIRT |

|Criminal Justice (CJ) |Local Sales Tax |Youth Treatment |

|Crim Just Hardship Insured |Molina – Managed Care | |

|4. FUND SOURCE (CHECK ONE BOX ONLY) |

| Agency Funded | Federal Direct | State Direct |

|County Community Services |Other |State DSHS (Non DASA) |

|DOC |Private Pay |Tribal Community Services |

|5. FUND SOURCE GAMBLING (CHECK ONE BOX ONLY) |6. TITLE XIX FUNDED |8. RECOMMENDED ASAM PLACEMENT LEVEL |

|State Direct Private Pay Other |Yes No |      |

|9. SPECIAL PROJECT STATE |10. SPECIAL PROJECT COUNTY |11. SPECIAL PROJECT AGENCY |

|      |      |      |

|12. GOVERNING COUNTY (IF NOT COUNTY OF FACILITY) |13. INSURANCE PAYMENT (PRIVATE) (CHECK ONE BOX ONLY) |

|      |No Insurance Payment 50% or greater Less than 50% |

|14. ADMISSION STAFF ID |15. COUNSELOR STAFF ID |16. ADMISSION DURATION |

|      |      |Hours:       Minutes:       |

|17. COURT ORDERED |18. DOC SUPERVISION |19. CONSENT STATUS |

|CD MH Both None |Yes No |Permitted Refused Revoked |

|20. CONSENT DATE |21. INTERVIEWER’S SIGNATURE |22. DATE |

|      | |      |

|NOTES |

|      |

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